GW1-2022-04056_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well contractor Informs on:
4 K° FROM 14. ATER 200NES DESCRnrnnR
Well Contractor Name ft. oft a
ft. tt.
NC Well Contractor Certification N er ti 15.OUTER CASING for motel-cased wells:OR LINER i1, cable
FItpM TO DIA11 TER THICKNESS MATERIAL
a lilt I P W
P ft. ft. ln. I . I A ,
Company Name k` I�.aA 66.INNER CASING OR TUIl1NG eothermat closed-loo
2.Well Construction Permit#: Kf t� t PROI►i TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pennits(t.e.VIC,County,State, ariance,eta)
ft ft. in.
tL ft. in.
3.Well Use(checkwelluse):
17.SCREEN
Water Supply Well: FROM TOq77=14AMIALAgricultural Municipal/Public ft.Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft
Industrial/Commereial []Residential Water Supply(shared) 18.GROUT
Ir7lQ tlOn FROM TO MATER AL F,MpLACF.111EVT HOD&AMOUNT
Non-Water Supply Well: R �' R•
Monitoring Recovery ft. tt.
Injection Well: M ft.
Aquifer Recharge [GroundwaterRemediation 19.SANDIGRAVELPACK ifs livable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACE111EM1T METHOD
Aquifer Test [Stonnwater Drainage ft, ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG.attach additional sheets if necess
FROM TO DFSCRIP'ITON color hardness,soiUrack e. in ' etc.
Geothermal(Heatiug/Cooling Return) Other(explain under 421 Remarks) ft
it
4.Date We4(s)Completed;
WeIIID# ft• .
ft. tt.
5a.Well Location:
A$ S I rS ft.
Facility ID# ifapplicable)
ft.
Facility/OwnerName tY ( ,.
o 54111 in tt. APR ` 2 2021
Physical Add ess City,and Zip
21.REhiAIiKS
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
Signatur of Certified Well Contractor Date
6.Is(are)the wells) Permanent or Temporary
By signing this form,I hereby certify that the uwll(s)was(were)constructed in accordmice
7.Is this a repair to an existing well: [Yes or M(No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the urll owner.
repair under#21 remarks section or on the back of this fonn. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
consttuctip only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lC7lJ (fL) 24a. For A11 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: '10 (ft.). Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (In.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
� �1�yn above,also submit one copy of thus forth within 30 days of completion of well
12.Well construction method: 1d T construction to the following:
(i.e.auger direct,rotary,cable, push,etc --
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY`WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Ott' Method of test: 9 ua 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address th address(es) above, also submit one copy of this for within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2-22 2016